Peel consent form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Are you pregnant or breastfeeding?
*
Yes
No
Have you had permanent make up applied
*
Yes
No
Do you currently use hair removal products or have you recently had facial, waxing? *discontinue use of any hair removal 5 days prior pre & post treatment
*
Yes
No
Are you currently using any topical retinol prescriptions? ( examples: trentinoin or retin-a) * consult your physician before discontinuing use of any prescription, however, it is recommended to discontinue use of these prescriptions 5 days pre & post treatment
*
Yes
No
Are you currently using Accutane?
*
Yes
No
If currently using Accutane for how long?
*
Have you previously had a chemical peel
*
Yes
last peel within the last 14 days
No
If you’ve had a peel before, what type of peel
*
Do you have regular collagen, or dermal filler injections? (Botox)
*
Yes
No
Have you recently had laser resurfacing?
*
Yes
No
Are you allergic/ sensitive to any of the following? *check all that apply
*
Milk
Apple
Citrus
Grapes
aloe vera
asprin
perfumes
latex
hydroquinone
Any other allergies
*
Are you taking any medications at this time
*
If no please enter “no”
What are the changes you would most like to see in your skin?
*
Please read and check off all boxes below.
*
I understand that a small amount of discomfort and flushing may be part of the chemical treatment. Stinging, heat and tightness are all normal.
I understand that due to many personal variables, that there are no guarantees as to the results of this treatment and I may need several treatments to see maximum results.
I understand that I may or may not actually peel and that each case depends on each individual’s personal variables.
I understand that this treatment is a cosmetic treatment and that no medics, claims are expressed or implied.
I understand that although complications are very rare, sometimes they occur.
I understand that extended direct sun exposure is prohibited preceding treatment, and the daily use of an SPF 30 is mandatory.
I have not had a chemical peel within 14 days of this treatment. I understand that I cannot have another chemical peel 14 data preceding this treatment.
I understand that I should follow my post treatment recommendations to minimize side effects and maximize results.
I give permission to my Esthetician to perform the procedures we have discussed and will hold her harmless from any liability that may result from these treatments.
Signature
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